Health Points

Are se­ri­ous games ready to cap­i­talise on their abil­ity to cure our ills?


Is the se­ri­ous-game sec­tor ready to cap­i­talise on videogames’ ter­rific po­ten­tial for heal­ing?

We’re in the en­gi­neer­ing and com­put­ing build­ing at Coven­try Univer­sity, at­tend­ing the Games For Health UK Con­fer­ence. It’s an ir­reg­u­larly shaped con­struc­tion, slant­ing and jut­ting in ways that defy old-fash­ioned ar­chi­tec­tural think­ing. And it’s held to­gether by gi­ant hexagons, them­selves ir­reg­u­larly pro­por­tioned, their im­per­fec­tions speak­ing of the nat­u­ral world. It feels like an ap­pro­pri­ate set­ting for a dis­cus­sion of what is in­creas­ingly touted as the fu­ture of medicine.

As Pamela Kato, pro­fes­sor of se­ri­ous games at Coven­try Univer­sity and chair of the con­fer­ence, in­tro­duces the day’s pro­ceed­ings, the au­di­ence sits back in er­gonomic chairs. The au­di­to­rium is packed with aca­demics, de­vel­op­ers and prac­ti­tion­ers keen to thrash out the land­scape of se­ri­ous games; where they are, and where they can go. Af­ter an ini­tial boom in the early 2000s, with a fo­cus on mil­i­tary train­ing and gam­i­fi­ca­tion, se­ri­ous games have dropped out of main­stream view. Health, though, marks one of the key ar­eas in which progress is be­ing made. Cru­cially, the po­ten­tial that ex­ists within the field is only just be­ing for­mu­lated.

You may re­mem­ber Re-Mis­sion or Snow World from the mid-noughties. They were, loosely speak­ing, the break­out hits of the se­ri­ous-game in­dus­try. Main­stream me­dia latched onto them as con­crete ev­i­dence of videogames’ ca­pac­ity to ef­fect pos­i­tive change, these be­wil­der­ing cre­ations act­ing as a sharp tonic to the neg­a­tive press in­ter­ac­tive en­ter­tain­ment can at­tract so de­pend­ably.

In Re-Mis­sion, re­leased in 2006, you play as a nanobot, in­jected into the body to fight off dif­fer­ent can­cers, in­fec­tions and the po­ten­tial side ef­fects of treat­ment such as chemo­ther­apy. It was de­signed to ef­fect be­havioural change in ado­les­cent can­cer pa­tients, to help as­sist in the de­liv­ery of po­ten­tially life-sav­ing chemo­ther­apy and an­tibi­otics. Kato – also found­ing pres­i­dent and CEO of Hopelab, the game’s pub­lisher – over­saw the project as well as con­duct­ing the most sci­en­tif­i­cally rig­or­ous ran­domised trial on the ef­fects of a game, results of which were pub­lished in 2007. “The kids who played our game took more of their chemo­ther­apy and also more of their an­tibi­otics,” Kato tells us. The game shipped 275,000 copies, dis­trib­uted through med­i­cal prac­tices across the US and other parts of the world. It was, at least in se­ri­ous-game terms, an em­phatic suc­cess, and pointed to what videogames are ca­pa­ble of in the con­text of health­care.

Snow World, de­vel­oped by Ari Hol­lan­der and Howard Rose at the Univer­sity Of Washington, was ac­tu­ally be­ing used a few years be­fore

Re-Mis­sion, with the first study into its ef­fects be­ing pub­lished in 2001. But the story around it has con­tin­ued to grow. In Snow World, play­ers – gen­er­ally burn vic­tims – don a VR head­set and fight off snow­men in an ice-cold set­ting. A mix of dis­trac­tion and psy­cho­log­i­cal per­sua­sion, the win­ter en­vi­ron­ment off­sets the painful heat sen­sa­tions the burn vic­tim might hold. And the game is played while painful ex­er­cises such as skin stretch­ing are be­ing un­der­taken, re­plac­ing, or used in con­junc­tion with, tra­di­tional drug-based pain-re­lief meth­ods. “VR pain re­lief de­liv­ers,” Rose, now CEO of Deep­stream VR, tells us. “And hav­ing that prece­dent is very im­por­tant.”

But it’s a prece­dent the se­ri­ous-game in­dus­try doesn’t ap­pear to have cap­i­talised on, at least to the ex­tent that was once forecast. Cer­tainly it’s a view that those within the in­dus­try are aware of. “I went to a con­fer­ence and some­one said to me, ‘OK, there’s Snow World and there’s Re-Mis­sion, but there’s noth­ing else. And your games are re­ally old’,” Kato re­calls. “That’s re­ally frus­trat­ing in the field.”

The unique na­ture of these games means that they can’t be com­pared to tra­di­tional re­leases. Their af­ter­lives, and the re­search pro­jects that un­der­pin them, set them apart. “We didn’t just make

Re-Mis­sion,” Kato ex­plains. “We said, ‘Does it work? Does it do what we said it would?’” And for Rose, pain-re­lief pro­jects at Deep­stream VR are in­formed and ad­vised on by Dr Alex Ca­hana, a pain doc­tor for 27 years and for­mer head of pain medicine at the Univer­sity Of Washington. These steps are, of course, ne­ces­si­ties. They’re cru­cial com­po­nents of

a process whose out­come must be safe and ef­fec­tive, and sub­ject to the same care­ful sci­en­tific eval­u­a­tion as any other new drug, treat­ment or prac­tice.

Richard Brady, a spe­cial­ist col­orec­tal sur­geon and the founder of Re­search Ac­tive, echoes not only the need for in­te­grated ex­per­tise in the de­sign process but also ro­bust reg­u­la­tion. “There are a lot of prod­ucts launched from ideas or in­no­va­tion that don’t al­ways have qual­ity re­search or data be­hind them to sup­port the claims that are made,” he tells us. He is, though, keen to em­pha­sise the po­ten­tial ben­e­fits in this shift to dig­i­tal means of treat­ment. “It holds great po­ten­tial in re­duc­ing costs of health­care, in pro­vid­ing con­sumer-led and pa­tient-cen­tred care, be­ing pa­perlight and ef­fi­cient, and be­ing able to col­lect lots of pop­u­la­tion-based data that we can use as medics to de­cide on fu­ture ad­vances in medicine.”

The ben­e­fits that might be felt are the re­sult of a fun­da­men­tal shift within health­care, from a model of treat­ment within a hospi­tal to one of pre­ven­tion and ther­apy through life­style. This, Kato tells us, lies at the heart of the push within games for health.

“Our health­care sys­tems can­not han­dle the fact that we have done so well by mak­ing peo­ple live so long,” she ex­plains. “When you live long, you get the gift of hav­ing a chronic ill­ness – heart dis­ease, can­cer, di­a­betes, de­men­tia. You go to the hospi­tal, you see a doc­tor, you have to take your med­i­ca­tion ev­ery day, you have to change your life­style, you have to eat dif­fer­ently. So how do you sup­port that? The ex­cite­ment around se­ri­ous games is that we can make those re­ally crit­i­cally im­por­tant be­hav­iours fun to en­gage in.”

Fun: that’s the cru­cial point. But it’s one that is missed by many se­ri­ous-game de­vel­op­ers. And it’s not only games for health that missed the mark – it’s a prob­lem that has plagued videogames used in a se­ri­ous way for the past 20 years, ed­u­ca­tional games bear­ing the brunt of the crit­i­cism. Tim Lan­ing of Gren­del Games is all too aware of the prob­lem and the cat­a­strophic ef­fect it can have on a prod­uct’s ca­pac­ity to de­liver the type of change it says it can.

“The rea­sons why some of these se­ri­ous games are fail­ing is be­cause they’re not games at all,” he says. “They’re not. They’re bor­ing. They nearly don’t

have any ac­tual game­play. The graph­ics look hor­ri­bly out­dated. And they might work from an aca­demic point of view, but if the tar­get au­di­ence is sim­ply not in­ter­ested, be­cause it’s not in­trin­si­cally mo­ti­vat­ing, then it’s not go­ing to work.” Right­ing that wrong is part of Lan­ing and Gren­del Games’ cur­rent mis­sion. The stu­dio’s tagline, ‘Se­ri­ously en­ter­tain­ing’, neatly pokes fun at the term se­ri­ous games, while also lay­ing out the fun­da­men­tal route these games need to take in or­der to be­come a suc­cess. It is, though, a stance that has evolved, along with the stu­dio.

Gren­del Games started out as a group of like­minded friends in 1998, based out of Lan­ing’s apart­ment in Leeuwar­den, a small city in the north of the Nether­lands. Gren­del’s ac­tiv­i­ties ramped up in 2003 when it en­tered into talks with Mi­crosoft about de­vel­op­ing a ti­tle for Xbox Live Arcade. That game,

Slave To The Blade, was “a mix of Guild Wars and Mor­tal Kom­bat”, Lan­ing says. Al­though the project would ul­ti­mately be can­celled by Mi­crosoft, de­mands made by the pub­lisher be­fore that point took Gren­del down an un­ex­pected, but fruit­ful, path.

Mi­crosoft wanted mo­tion-cap­tured an­i­ma­tion in the game – some­thing of which Gren­del had no ex­pe­ri­ence. So the team turned to a lo­cal mo­tion­cap­ture com­pany, Motek En­ter­tain­ment, to as­sist in de­liv­er­ing it. But as Slave To The Blade teetered back and forth, Gren­del was of­fered an op­por­tu­nity by Motek’s sis­ter com­pany, Motek Med­i­cal, to de­velop a game for mil­i­tary re­ha­bil­i­ta­tion us­ing in­frared mo­tion cap­ture. Motek Med­i­cal had al­ready tried and failed to make the con­cept work on its own. Now it was Gren­del’s turn. It was with this project that the com­pany ethos be­gan to be forged.

“Ba­si­cally, the tar­get au­di­ence didn’t like what Motek Med­i­cal had built,” Lan­ing tells us. “Aca­demics liked it, physi­cians liked it, but the tar­get au­di­ence – in­fantry peo­ple who had stepped on land­mines and had lost their ex­trem­i­ties – didn’t like it. The prob­lem be­came clear and the so­lu­tion be­came im­me­di­ately clear. These were all young guys, guys our age. They were ac­cus­tomed to play­ing videogames on their PlayS­ta­tions and Xboxes that looked like ac­tual videogames. The games them­selves were not fun at all. So that’s when we de­cided to take a look at it.”

That project led to fur­ther se­ri­ous-game work, and grad­u­ally the ghost of Slave To The Blade was pushed to the back of the team’s minds. Gren­del con­tin­ued its ex­plo­ration of re­ha­bil­i­ta­tion in Gryphon

Rider but with a shift in fo­cus away from mil­i­tary per­son­nel to­wards chil­dren, typ­i­cally those suf­fer­ing from cere­bral palsy or brain dam­age. Us­ing Mi­crosoft’s Kinect, the player guides their char­ac­ter through a fan­tasy world us­ing de­lib­er­ate body move­ments. The game, iron­i­cally, takes ad­van­tage of Kinect’s fail­ures and re­pur­poses them for an au­di­ence that re­quires a slower type of game. “Kinect failed be­cause it did a lot of things wrong,” Lan­ing notes. “It tried to work around the fact that it was quite laggy and would have all these other prob­lems. But what Kinect can do very well is per­ceive slow mo­tions very ac­cu­rately to con­trol some­thing.”

The game is also en­tirely cus­tomis­able, al­low­ing par­ents and prac­ti­tion­ers to quickly and ac­cu­rately al­ter set­tings in or­der to meet the phys­i­cal needs of the child play­ing. “You can press pause and then it will show you all the hur­dles that are there and you can in­crease or de­crease the dif­fi­culty,” Lan­ing ex­plains. “But you can also set it up so that chil­dren can play it who are able to only move their left arm.” There’s of­ten talk of cus­tomi­sa­tion em­pow­er­ing the player, giv­ing them the ex­pe­ri­ence that they want, but Gryphon Rider goes fur­ther, giv­ing play­ers the ex­pe­ri­ence they need while also giv­ing them a pro­found sense of em­pow­er­ment and agency. This, af­ter all, is a game de­signed specif­i­cally for them, where they might usu­ally be ex­cluded be­cause of the dex­ter­ity re­quired to use a typ­i­cal con­troller.

Cus­tomi­sa­tion also lies at the heart of Howard Rose and Deep­stream VR’s cur­rent project, Cool. Like Rose’s pre­vi­ous project, Snow World, it’s be­ing used in chronic-pain clin­ics and for acute pain re­lief in hospi­tals. The ex­pe­ri­ence this time, though, is more open-ended, de­signed to in­cor­po­rate a broader range of pa­tients. And part of this drive is the in­te­gra­tion of wear­able body tech­nol­ogy. “The big leap is to bring sen­sors into this,” Rose ex­plains. “With the rise of wear­able com­put­ing, it’s not just


the same ex­pe­ri­ence ev­ery time. It’s cre­at­ing a world [play­ers] can come and ma­nip­u­late. The vir­tual re­al­ity knows you and adapts.”

That adap­ta­tion is down to the data-col­lec­tion pos­si­bil­i­ties of games for health. “VR is some­thing that [prac­ti­tion­ers and clin­i­cians] can track. We can get all this data, and then ad­just it,” Rose says. “You can mod­u­late it in re­al­time to say: ‘Well, that’s work­ing? That’s not work­ing? Let’s try this.’ It en­ables peo­ple, I think, to be bet­ter at that re­ha­bil­i­ta­tion model.” That flex­i­bil­ity is some­thing Lan­ing is keen to stress, too. “You can lit­er­ally prescribe play­ing lev­els much like you would prescribe medicine for the re­ha­bil­i­ta­tion of your child,” he says.

But games for health aren’t just be­ing used for treat­ment and re­ha­bil­i­ta­tion. They’re also be­ing used to aid in the train­ing of prac­ti­tion­ers, par­tic­u­larly sur­geons. Gren­del’s big­gest com­mer­cial suc­cess to date, Un­der­ground – re­leased on Wii U – is a la­paroscopy (more widely known as key­hole surgery) sim­u­la­tor in every­thing but name. It’s a puz­zle game in which you guide two ex­plor­ers through a fan­tas­ti­cal un­der­world but, cru­cially, it utilises a novel con­trol me­chanic that mim­icks the tools used to carry out real-world la­paro­scopic surgery. Though the game was re­leased in 2015, the con­trol method was pro­to­typed on the orig­i­nal Wii hard­ware. “The Wii Re­mote is very ac­cu­rate but not when you’re fling­ing it around,” Lan­ing says. Gren­del went on to de­sign a cus­tom con­troller for spe­cial­ist use: the de­vice costs $250, and it’s been in­cor­po­rated for la­paro­scopic train­ing at fa­cil­i­ties around the world. Gren­del is keen to de­velop this com­mit­ment to sur­gi­cal train­ing. The week af­ter we speak, Lan­ing and other rep­re­sen­ta­tives of the stu­dio will fly out to the US to shore up the de­tails of their big­gest project to date, part­ner­ing with two of the largest sur­gi­cal com­pa­nies in the world. De­tails at the mo­ment are hazy but Lan­ing tells us, “It’s ei­ther go­ing to be mixed re­al­ity com­bined with a ded­i­cated con­troller, or it might be­come VR.” And de­spite the prac­ti­cal ap­pli­ca­tion of the tech­nol­ogy, it will still fall in line with Gren­del’s ethos. “It’s go­ing to be an ac­tual game like the other games we’ve built, with high pro­duc­tion val­ues but cater­ing to a com­pletely dif­fer­ent pub­lic.”

In work­ing with es­tab­lished part­ners in the med­i­cal field, Gren­del is cre­at­ing a dis­tri­bu­tion model as well as fos­ter­ing trust with po­ten­tial users, a cru­cial fac­tor in the wide­spread adop­tion of games for health. “As far as I know, Gryphon Rider is the only game that is be­ing dis­trib­uted, and re­im­bursed, by a health in­sur­ance com­pany,” Lan­ing says. “And I think that’s im­por­tant be­cause peo­ple need to ac­cess it. And if it be­comes recog­nised as a whole­some ther­apy and a health in­sur­ance com­pany stands be­hind it, that’s a re­ally good sig­nal for par­ents at home, be­cause it’s re­ally hard for them to tell what’s good from what isn’t.”

That trust is also sup­ported through the em­bed­ding of sci­en­tific ex­per­tise and eval­u­a­tion into the de­sign process, some­thing Gren­del has worked hard to cul­ti­vate. “We have two share­hold­ers – one a hospi­tal and the other a health in­sur­ance com­pany,” Lan­ing ex­plains. “Which makes sense for us be­cause we get to cre­ate a busi­ness case based on the statis­tics, and we get to prove what we’re do­ing to­gether with the univer­sity med­i­cal cen­tre by find­ing the right peo­ple world­wide that can help us.”

The ben­e­fits are ob­vi­ous. And that level of sci­en­tific eval­u­a­tion is some­thing Gren­del takes in­cred­i­bly se­ri­ously. It’s the rea­son why Un­der­ground took seven years to make and Gryphon Rider took four. “You have to it­er­ate ev­ery step of the way and make sure it does what you claim it does,” Lan­ing ex­plains. “What’s ba­si­cally lit­ter­ing the se­ri­ous-game in­dus­try right now is a mine­field of very badly de­signed se­ri­ous games that don’t do what they claim to be do­ing.”

The risks in­volved in poorly de­signed games for health are man­i­fold. It’s not just a case of feel­ing


irked that time has been wasted, as might be the case with a tra­di­tional game. Safety is key – there’s the po­ten­tial that harm could be en­acted, par­tic­u­larly in the case of a poorly de­signed re­ha­bil­i­ta­tion game, for ex­am­ple, that pushes the body too far or in the wrong ways. Test­ing, re­flec­tion and it­er­a­tion must be in­cor­po­rated at ev­ery step of the de­vel­op­ment process. The down­side is that all of these things take time, a point Lan­ing stresses through­out our dis­cus­sion.

“What you need to un­der­stand is that every­thing in medicine is slow, but it’s also very de­lib­er­ate,” he says. “I never got that when I went to the first games for health con­fer­ences.” But it’s not only be­cause of test­ing and reg­u­la­tion. “Medicine is a multi­bil­lion­dol­lar busi­ness. I mean, the game in­dus­try is large, but the med­i­cal in­dus­try is a lot big­ger.” Health­care, then, is a lurch­ing be­he­moth in com­par­i­son to the fleet-footed videogame in­dus­try.

There’s no doubt that, al­though games for health have proven their value in cer­tain cir­cum­stances and ap­pli­ca­tions, it will take time for their po­ten­tial to be re­alised ex­ten­sively, and for their wide­spread in­te­gra­tion into health prac­tices. And it will take more com­pa­nies such as Gren­del to push it for­ward. With its em­pha­sis on fun, rig­or­ous re­search, and adop­tion not only by con­sumers but cor­po­ra­tions, plus re­gional and na­tional gov­ern­ments, the com­pany is paving the way for fu­ture de­vel­op­ers in the field.

Lan­ing is quick to em­pha­sise the lim­i­ta­tions of such a fledg­ling field, how­ever. “I’m not say­ing videogames are a so­lu­tion for every­thing,” he says. “They’re not. They’re ab­so­lutely not.” But given an in­creas­ingly age­ing pop­u­la­tion, and the rise in chronic ill­nesses that has emerged as a con­se­quence, so­ci­ety and its gov­ern­ments are duty bound to ex­plore ev­ery pos­si­ble op­tion. Games are not some form of ul­ti­mate cure, but if they’re im­ple­mented prop­erly, they can only be­come in­creas­ingly ef­fec­tive parts of health­care. “We hope to be an ex­am­ple of how you should pull it off,” Lan­ing smiles.


Pamela Kato, pro­fes­sor of se­ri­ous games at Coven­try Univer­sity

ABOVE Rose hopes to cap­i­talise on the rise of con­sumer VR for games such as Cool. “Ul­ti­mately, we want to help peo­ple at home.” RIGHT We­ston, a young suf­ferer of chronic pain, plays Cool us­ing an HTC Vive head­set. The pain-re­lief ben­e­fits have been shown to last up to 48 hours af­ter treat­ment 7

Dr Ted Jones has been us­ing VR to treat pain re­lief at his clinic, the Pain Con­sul­tants of East Ten­nessee. Here he guides a pa­tient through Deep­stream VR’s Cool

Richard Brady, founder of Re­search Ac­tive

Howard Rose, CEO of Deep­stream VR

A can­cer pa­tient us­ing a Deep­stream 3D viewer pro­to­type. Pa­tients don’t note any side ef­fects when play­ing Deep­stream VR’s pain ap­pli­ca­tions

Tim Lan­ing, founder of Gren­del Games

Un­der­ground is avail­able via Nin­tendo’s dig­i­tal store, with 90 per cent of copies sold to hospi­tals and skills labs. It has a cus­tom con­troller (right), but it can also be played more tra­di­tion­ally, us­ing the Wii U GamePad

ABOVE Garfield­GoesTo

Town is be­ing adapted for ter­ri­to­ries across the world with food types spe­cific to each re­gion.

RIGHT Chil­dren have played an im­por­tant role in Garfield­GoesTo Town’s de­vel­op­ment, pro­vid­ing feed­back to Gren­del through QA re­ports. The NHS has fa­cil­i­tated this through its con­nec­tions with schools

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